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HEPATIC HCO 3 – “PRODUCTION” AND CONSUMPTION principal 1.The liver is the principal organ that clears lactic acid produced by different tissues of the body 2.Each mole of lactic acid is accompanied by a mole of H +. oxidationgluconeogenesis 3.Lactic acid taken up can be metabolized by two pathways; either oxidation to CO 2, or gluconeogenesis to form glucose and glycogen. 4.Removal of free H + during lactate metabolism in effect increases the available HCO 3 – pool by diminishing its consumption. stimulates 5.Decreased ECF pH stimulates hepatic lactate uptake unless the liver itself is ischemic or hypoxic. synthesis of urea 6.Countering H + consumption during lactate metabolism is HCO 3 – consumption during synthesis of urea from protein and amino acid catabolism. Urea synthesis, which occurs only in the liver, can be written empirically as 7.Eachtwo 30g urea1,000 mmol of HCO 3 – 7.Each mole of urea synthesis consumes two moles of HCO 3 –. Urea produced by the liver is excreted in the urine. A normal daily excretionof 30g urea in the urine translates to the equivalent of 1,000 mmol of HCO 3 –

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ANALYTIC TOOLS USED IN ACID-BASE CHEMISTRY The clinical significance of acid-base perturbations is determined by the underlying cause rather than the serum concentration of hydrogen and hydroxyl ions. The accuracy of acid-base measurements, however, is not determined by the blood gas value alone, which measures volatile acid and pH. Rather, measurement of each of the strong and weak ions that influence water dissociation, although cumbersome, is essential.

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Carbon Dioxide-Bicarbonate (Boston) Approach First, the approach is not as simple as it seems, requiring the clinician to refer to confusing maps or to learn formulas and perform mental arithmetic. Second, the system neither explains nor accounts for many of the complex acid-base abnormalities Many physicians have incorrectly assigned the increase in HCO 3 - as compensation for raised PCO 2. It is not. The increased HCO 3 - concentration reflects increased total CO 2 in the body. Alterations in HCO 3 - reflect its role as a buffer, CO 2 by-product, and weak acid.

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Base Deficit or Excess (Copenhagen) Approach These measures may miss the presence of an acid-base disturbance entirely; for example a hypoalbuminemic (metabolic alkalosis), critically ill patient with a lactic acidosis may have a normal range pH, bicarbonate, and BE. This may lead to inappropriate therapy.

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Anion Gap Approach The first and most widely used tool for investigating metabolic acidosis is the anion gap (AG), developed by Emmit and Narins in 1975 This is based on the law of electrical neutrality Na + + K + - (Cl − + HCO 3 − ) = -10 to -12 mEq/L ??? If the gap "widens" to, for example, -16 mEq/L, the acidosis is caused by UMAs (lactate or ketones).

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what is or is not a normal gap? Most critically ill patients are hypoalbuminemic, and many are also hypophosphatemic. Corrected anion gap: Anion gap corrected (for albumin) = calculated anion gap + 2.5 × (normal albumin [g/dL] − observed albumin [g/dL]) The second weakness with this approach is the use of bicarbonate in the equation. An alteration in [HCO 3 - ] concentration can occur for reasons independent of metabolic disturbance, such as hyperventilation. The base deficit (BD) and AG frequently underestimate the extent of the metabolic disturbance what is or is not a normal gap? Most critically ill patients are hypoalbuminemic, and many are also hypophosphatemic. Corrected anion gap: Anion gap corrected (for albumin) = calculated anion gap + 2.5 × (normal albumin [g/dL] − observed albumin [g/dL]) The second weakness with this approach is the use of bicarbonate in the equation. An alteration in [HCO 3 - ] concentration can occur for reasons independent of metabolic disturbance, such as hyperventilation. The base deficit (BD) and AG frequently underestimate the extent of the metabolic disturbance Anion Gap Approach